by ochiai808

What happens when you introduce something to look forward to in a situation that is bleak and both a psychological and physiological struggle?  This can be the difference that allows for motivation to adhere to treatment regimens for those with medical difficulties.  In fact, the two articles we will discuss this week look at methods for improving adherence to treatment of chronic diseases in children via positive reinforcement.  The importance from these studies stem from the fact that poor adherence is a common problem which, in many cases, is the underlying cause of poor clinical outcomes. Therefore, this may “lead to misconceptions regarding the efficacy of the treatment,” sometimes creating what merely “appears to be a ‘treatment resistant’ disease” (Luersen et al. 5).  The treatment is then perceived to be the problem when, in actuality, the problem is the patient’s willingness to faithfully and correctly stick to the treatment.

Luersen et al. look at this problem of variable adherence and it’s importance as a factor in clinical outcomes.  They review other studies which implement sticker charts to instrumentally train children with chronic diseases to adhere to their respective treatment regimens.  Each time the child completes their specific treatment or reach specified intake levels of substances, the child receives a sticker.  This type of positive reinforcement via the application of a sticker is thought to do two things: (1) It provides the children with an immediate sense of gratification and (2) It helps remind the children (and parents in some cases) whether a treatment has been completed and when the next dose is due.  I will lightly touch upon the studies Luersen et al. focus on but please feel free to look into the specifics involved at  Following is an example of a sticker chart:


In a study by Stark et al., 4-12 years old cystic fibrosis patients are rewarded with a sticker each time a calorie goal is met. When compared to control groups, results include greater increase in caloric intake, weight gain, and BMI which was maintained during follow-up testings.

In another study by Stark et al., 4-10 year old juvenile rheumatoid arthritis patients are rewarded in a stepwise fashion with one sticker per increase in calcium intake per meal and for meeting specified calcium goals.  When compared to control groups, results include an increased calcium adherence and greater body bone mass.  Patients 5-12 years old with inflammatory bowel disease also participate in this same type of sticker program which similarly results in an increase in calcium intake and a greater percentage of patients achieving their set calcium goals.

The study of Cass et al. involve tuberculosis patients who are 1-14 years of age.  The introduction of sticker charts in which they are rewarded one sticker for each daily tuberculosis medication ingested makes children 2.4 times more likely to complete their latent tuberculosis infection treatment.

Slifer et al. study 3-5 year old patients with breathing disorders and how the sticker charts increase nightly BiPAP (Bilevel positive airway pressure) use.

In a study by Penica et al., a 2 year old hemophiliac child is rewarded with a sticker for adherence during the IV infusion of clotting factors.  This results in both the decrease in negative behavior and increase in positive behavior during the infusion process.

Luersen et al. findings therefore support their claim that the sticker charts are effective at increasing adherence to therapy in children with chronic disease.  Moreover, the effect is robust, working across a wide variety of chronic pediatric diseases.  What’s important about this is that these interventions improved the clinical outcomes, which is the ultimate goal of the adherence modifying methods.  What is the reason for the apparent success of this approach?  One can speculate that introducing a reward program gives the patients something to look forward to and want to work for.  It is something positive in their already adverse and tiresome life.  Medical difficulties, especially chronic diseases, not only burden the body but also have significant psychological ramifications.  It is not normal for a child to have to go through the demanding treatments, to be restricted from everyday activities, to be constantly worrying about their health.  Therefore, giving them some kind of encouragement, something rewarding, something positive is extremely important.  The desire to adhere to their treatments is instilled through this instrumental positive reward.

To further understand this type of instrumental conditioning, specifically positive reinforcement, let us now go in depth into one of the studies which results in similar findings as the studies above. This four patient study by Magrab et al. include one 11-year old, two 13-year olds, and one 18 year-old, all of whom are in the pediatric hemodialysis unit receiving dialysis treatment 2-3 times a week.  A serious problem among all four subjects, which is actually common for many pediatric patients undergoing dialysis treatment due to renal failure, is adherence to strict dietary restrictions.  Failure to follow the prescribed diets results in “increase risk for fluid overload and congestive heart failure, hypertension, hyperkalemia, azotemia, and bone disease” (Magreb et al. 573).  Because few techniques are found to be successful at maintaining compliance to the dietary restrictions, Magrab et al. wish to test the success of a token economy on these type of patients.  Their token economy is a bit different than the conventional in that only reinforcement is delivered (never is anything taken away).  In order to receive a reinforcement of 2-3 points, weight gain between dialysis sessions must be equal to or less than 2 pounds.  Weight gain is used as a measure of fluid intake, and 2 pounds represents the largest amount of fluid safe for dialysis.  Eighteen points are equivalent to $2.00 for purchasing prizes or rewards.  What is unique about the specific reward system of this study when compared to the previous studies discussed is that it is a “specially for you” system.  The children are allowed to construct their own prize list and indicate specifically what rewards the want to work for (as long as it is not food).  In addition, a chart which records their respective point achievements is posted in a very visual location in the unit for further motivation and recognition.  Each week the child’s point count is gathered, and he or she is allowed to exchange the earned points for their predetermined prizes.

Thankfully, the results of Magrab et al. are promising.  Compared to the baseline data, a reduction in the amount of weight gained found is found between dialysis sessions such that the average baseline gain is 2.18 lbs while the average treatment gain is .97 lbs.  In addition, a substantial change in the percentage of sessions in which the patients exceed acceptable weight gains decreases from a baseline of 47% to 20% during treatment.  It is also noticed that any extreme weight fluctuation that occurs during baseline is reduced during treatment.

Again, it can be hypothesized that the reason why this type of reward system is successful is because many psychosocial adjustments must be made when one is ill and “severe restrictions or major changes in eating style may become further barriers to normal social activity” (Magrab et al. 573).  Therefore, many more negative things are introduced into the lives of these patients.  By introducing something positive, these children have something to look forward to, something to work for.  This essentially enhances the quality of their lives and provides a type of “life motivation” (Magrab et al. 578).  A reward system can also give the patients a sense of control over something in a situation they have little control over.  They gain a sense of power over their present states.  Moreover, the special thing about this case is that the children are able to choose exactly what they want their reward to be.  This then tweaks the system so that the motivation to complete the task, to adhere to their dietary restrictions, is greatest.  In the other studies, the value of stickers may be different from one patient to another.  However, in this study, the value of the reward is high for all patients.


Magrab, P. R. & Papadopoulou, Z. L. (1977) The effect of a token economy on dietary compliance for children on hemodialysis. Journal of Applied Behavior Analysis, 10(4), 573-578.


Luersen, K., Davis, S., Kaplan, S., Abel, T., Winchester, W., & Feldman, S. (2012) Sticker charts: A method for improving adherence to treatment of chronic diseases in children. Pediatric Dermatology, 1-6.